Stereotactic Radiosurgery

Aneurysm

I have an aneurysm of my brain, and I was told that I can have it treated with brain surgery or a coil through my leg. What is the best treatment?

An aneurysm is a weakness in a wall of a blood vessel and can cause serious brain damage or even death if it breaks within the brain.

We now have ways to diagnose aneurysms before they bleed and can save many lives with early treatment.

A neurosurgeon who specializes in aneurysm surgery can review your case and based on the location of the aneurysm, the size of the aneurysm, and other data, determine whether it is safest to treat your particular aneurysm with surgery to clip the aneurysm off or by placing coils within the aneurysm through a catheter that enters the groin/leg.

There are pluses and minuses to each treatment so I recommend that you be evaluated by a specialist familiar with both types of treatment.

Back Pain

I get back pain and thigh pain on both sides whenever I stand for awhile or walk a short distance. The pain goes away almost immediately when I sit down. What's going on?

Dr. Dennis S. Oh says:

Your description essentially defines a condition called neurogenic claudication. It is the result of compression of the spinal nerves due to narrowing of the spinal canal in the lumbar region.

The upright position accentuates the narrowing and causes these symptoms to worsen with walking. Sitting down, on the other hand, opens up the narrowed segment to some degree and this relieves the pressure on the spinal nerves. Some patients tend to bend forward when walking, or lean on a counter or shopping cart for relief.

I've had low back pain for several days now. At what point do I need to see a neurosurgeon?

Dr. Dennis S. Oh says:

Acute episodes leave patients quite debilitated during this difficult time. It may be helpful to know though that eight out of ten Americans experience this problem at some point. More reassuring is the fact that in 90 percent of cases, patients improve without having surgery.

Your doctor will likely advise some rest, anti-inflammatory agents, pain medications, physical therapy or even steroid injections. We usually allow for 6-10 weeks of conservative management before considering the option of surgery.

Surgical decision-making then proceeds based on your clinical presentation and abnormalities seen on imaging studies such as spinal MRI.

Brain Cysts

My daughter has been getting a lot of headaches so our doctor finally ordered a brain scan which showed a cyst in her brain. No surgery has been recommended. Is there anything else we should do?

Dr. Dennis S. Oh says:

With the increasing availability of MRIs, we have been encountering more and more brain cysts that are found incidentally. These are usually harmless tiny cysts that are regarded as non-symptomatic.

Their appearance on MRI and the patient’s symptoms are taken into consideration when assessing whether surgery is needed. If no adequate reason is found to justify performing brain surgery, your neurosurgeon will most likely request follow-up MRIs in the subsequent months and years to make sure that the cyst does not grow undetected.

Brain Tumor

I have heard that brain tumors can now be treated without an incision. How can that be done?

One of the advances in the treatment of brain tumors and some blood vessel malformations is with Radiosurgery, a type of extremely well focused radiation therapy.

With the opening of Baystate's new Radiosurgery Center, some tumors and blood vessel malformations, which would have required surgery in the past, now can be cured without any incision or operating room.

The best advice is to see your neurosurgeon and learn which of these advanced technologies would be useful in your particular case.

The result of our mother's MRI was just released and it showed that she has a brain tumor. Is this the end of the line?

Dr. Dennis S. Oh says:

No. While almost nothing can be scarier than being diagnosed with a brain tumor, it is treatable in many instances. It all depends on the type of tumor and sometimes on its location in the brain.

Generally speaking, most “benign” brain tumors are treatable with surgery or other means, while cancerous ones have a much less favorable prognosis.

Some of us refrain from using the word “benign” to describe brain tumors, even if the biopsy shows no cancerous features, because they can still cause dangerous brain compression and be life-threatening.

There are many newer techniques being used today which make the treatment of brain tumors safer and more effective.

We have advanced imaging that can give surgeons a three dimensional view of the tumor using just a regular MRI scan.

We are using a computer guidance system in the operating room which essentially acts as a “GPS” for the brain—allowing us to localize tumors accurately before we even make an incision. This means smaller openings and less trauma to the brain during the surgical procedure—and less time for recovery.

Chiari Malformation

My 12-year-old daughter has terrible headaches in the back of her head and numbness and tingling in her arms. Our doctor ordered an MRI and told us she has a "Chiari malformation". What is this?

A “Chiari malformation” usually means that part of the cerebellum of the brain is pushing down through the foramen magnum - the hole at the base of the skull where the brain turns into the spinal cord. The pressure from this on the spinal cord and brain can cause a multitude of different symptoms.

This diagnosis is often overlooked as the findings on MRI are sometimes subtle. It is best to have your daughter examined by a neurosurgeon and review the MRI together. She/he can tell you if surgery - removing some bone at the base of the skull, and putting a patch down to give the brain and spine more room - would help your daughter.

Concussion

My son just suffered a concussion. How long will it be before he can return to sports?

Dr. Dennis S. Oh says:

Concussion is a traumatic injury to the brain that is caused by blunt force. This may be brought about by car accidents, falls or sports-related injuries.

Symptoms include headaches, loss of concentration or memory, dizziness, nausea and confusion. No specific treatment is required except rest and avoidance of repeat injury until full recovery with resolution of concussive symptoms.

In mild cases, players may be allowed to return to the game after 20-30 minutes, but in more severe instances, it may take weeks for symptoms to resolve.

In general, clearance is given after symptoms disappear, usually a month after the initial injury.

Herniated Disc

I have sciatic-type pain. Physical therapy and steroid injections have not helped. My doctor said that I have a herniated disc pinching a nerve and referred me to a neurosurgeon. What can I expect?

Dr. Dennis S. Oh says:

You can expect a thorough examination during your neurosurgical visit. Your clinical signs and the MRI picture serve as guides in the assessment of whether surgery will be beneficial.

If your neurosurgeon finds good correlation between your symptoms and the particular nerve that is pinched, then he or she will likely recommend a microdiscectomy. This is a relatively low-risk procedure that involves removing or shaving off the protruding portion of the disc to relieve the nerve compression. Success rates are very high in improving leg pain. Any associated numbness or weakness may also get better.

I have right-sided neck pain that extends to my shoulder blade region and down my right arm. I also have numbness in the thumb and forefinger. Can these problems be due to disc herniation?

Dr. Dennis S. Oh says:

The short answer is yes. If the disc herniation is large and compresses the correct nerve, it can cause pain and numbness in the manner that you described.

Whenever a nerve is compressed to a significant degree, it may manifest in three ways: pain, numbness or tingling, and weakness.

It is extremely important, however, that we are able to correlate a patient’s specific set of symptoms with the abnormality seen on imaging such as MRI. If the MRI only shows a small disc bulge with no nerve compression, or if the location is inconsistent with the clinical characteristics of the patient, then surgery may not lead to any appreciable improvement.

I've been diagnosed with three herniated discs but my spine surgeon refuses to operate on me. Why doesn't he want to help me?

Dr. Dennis S. Oh says:

It’s not that your surgeon does not want to help, but in many instances, operating on disc herniations or bulges does not lead to any added benefit over conservative treatment.

In spine surgery, it is extremely important to correlate a patient’s symptoms and physical exam findings to the structural abnormality seen on imaging studies such as an MRI.

Success rates depend not only on the surgeon’s skills but also on his ability to identify the appropriate surgical candidate. It is equally important to choose the right type of surgery for a given patient in this rapidly expanding field.

Hydrocephalus

My father has been gradually experiencing difficulty walking and slow mental decline. We've been told that he may have hydrocephalus. What can be done?

Dr. Dennis S. Oh says:

Normal Pressure Hydrocephalus (NPH) is one of the most under-recognized yet treatable conditions affecting the brain. It is characterized by impaired absorption of cerebrospinal fluid (CSF), resulting in accumulation of this fluid in the compartments called the ventricles. This expanded volume of CSF causes pressure on certain parts of the brain in a manner that produces a number of neurologic symptoms including gait deterioration, loss of urinary bladder control, and dementia.

There is some symptom overlap with Alzheimer’s and Parkinson’s, but when NPH is properly diagnosed, it can be successfully treated with a relatively simple procedure called shunting.

Hydrocephalus, a condition where there is an excess amount of fluid in the brain, has been traditionally treated with placement of a catheter that channels fluid from the brain to the abdomen. It is commonly referred to as a shunt. Problems that may arise with a shunt system include too much drainage or not enough drainage.

In the past, it may require additional surgery to replace the valve that controls flow. Now we have programmable valves that can be adjusted in the office with the press of a button by using a specialized magnet. Some patients may also be candidates for an endoscopic procedure that creates an internal channel for drainage without placing a permanent catheter.

Minimally Invasive Spinal Surgery

With advances in minimally invasive surgery in many fields, are there any such developments in spine surgery?

Yes. Some of the Minimally Invasive or Minimal Access techniques in spinal surgery have actually been around for a while, but popularity and applications have been expanding recently.

One example is the use of tubes as working channels to gain access to the spine instead of traditional wider openings. Not only does this technique allow for a small incision, but the approach simply parts the muscle fibers in the back instead of having to cut through them. This results in much better anatomic and physiologic preservation to achieve the same goals as traditional surgery.

For the patient, it means less pain and faster recovery. We would be happy to provide you with more information.

Pituitary Tumor

My father has a pituitary tumor that has progressed. He is now considering neurosurgery. What is the most advanced treatment option?

There are several treatment options, but the choice has to fit the right patient.

Some pituitary tumors or adenomas can be successfully treated with medication. Some are just observed through periodic MRI’s. However, if your father has been deemed in need of intervention, he will probably need surgery that involves going through the nose to reach the base of the brain where the pituitary is located.

The good news is that this technique has undergone a lot of refinement recently and can now be done using endoscopes to avoid excessive soft tissue destruction while giving a more close up view of the surgical field. This can also be achieved with a microscope.

One of the big advantages is the avoidance of postoperative nasal packing which is usually the most painful and troublesome part of the process.

First of all, pituitary tumors are managed by a team of doctors usually composed of your primary care physician, an endocrinologist, an ophthalmologist and a neurosurgeon. A thorough analysis of your hormones and vision are necessary in addition to a brain MRI.

Some tumors such as prolactin-secreting ones respond to medications and do not usually require surgery. Others that are not responsive to medication and are large enough to cause compression of the adjacent optic nerves (for vision) generally require surgical removal. This is sometimes followed with radiation treatment. Surgery in most instances involve going through the nose without any need of opening the head. It is becoming less and less invasive with the use of endoscopes.

Stereotactic Radiosurgery

What is stereotactic radiosurgery and how does it differ from Cyberknife and Gamma Knife?

Dr. Dennis S. Oh says:

Stereotactic Radiosurgery (SRS) is the general term for several different systems that work similarly in delivering precise radiation doses to treat brain tumors and other brain abnormalities. These include the Gamma Knife, Cyberknife, X-Knife, Brainlab Novalis, Peacock, Clinac, and others.

SRS uses computer-generated 3-D images of a patient’s brain that serve as a detailed roadmap for guiding radiation beams to the desired target. These beams pass through the skull harmlessly and, because of the pinpoint accuracy, can be delivered in very high doses without damaging the normal surrounding brain structures.

There is no incision and no hospitalization. For adults, general anesthesia is not needed.